Mr. Ryan's bad day...

So, why 12-lead EKG's? I've been in EMS for 20 years, all of it as a Paramedic. Back then, throwing my patient on a LifePak5 was normal for a patient with chest pain. Really, you were just watching to see if they were having FLBs (funny little beats), or something worse that had been drilled into us during ACLS!

You have to admit, though... Even in the ER, once you'd gotten them there safely (with prophylaxis Lidocaine pushed "just in case." golly, those were the days!) the tone of the physicians was that of "you've HAD a heart attack."

As most of us realize today, that attitude has changed 180 degrees! An MI is an evolution! "Time is muscle!" Everything we do (and don't do) in the field has a drastic impact on the mortality of the patient suffering from restricted blood flow through the coronoary arteries! Chest pain is a symptom of an EVENT, that of one that we, as prehospital providers, are in the middle of. Not simply transporting the victim of unfortunate circumstances.

So, knowing what we know today (and that we'll learn as we follow this blog through IT'S evolution), let's look back and remember why a thorough evaluation of a patient more often than not includes the acquisition of a 12-lead EKG.

Let's begin our adventure with our arrival on scene of Mr. Ryan...

*** Case Study #1 - Mr. Ryan ***

Mr. Ryan is a 54 year old male patient, 5'10" and 240 lbs. He's found sitting on the edge of his bed, dressed in only a pair of shorts, as it's 05:30 hrs. He states that he'd awakened feeling fine, but after walking to the bathroom to pee and brush his teeth, he began having 6 / 10 chest pain, which he describes as crushing and heavy substernally, and it radiates into his shoulder as though he's been throwing baseballs all night long.

At first glance, he looks pale and is clearly diaphoretic. He also looks very uneasy sitting there. He's an educated man, and it's clear that he understands the severity of his symptoms.

Your partner steps in while you're talking and establishes an initial set of vital signs. His heart rate is 78 and regular, with a blood pressure of 168/92. His respiratory rate is 20, and his oxygen saturation reads 92%. He denies nausea or any other complaints other than just a little bit of dyspnea walking back from the bathroom.

He states that his medical history includes controlled hypertension and migraines. He denies any drug allergies, and points you to his pill bottles on the dresser. You find three, including metoprolol (200mg daily), propranolol (160mg twice daily), and alprazolam (2mg prn).

Your partner, while you're looking at the medications, attaches the monitor. She states that it "looks OK." You take a look, and see the following:


An engine crew has arrived and has brought your stretcher to the bottom of the stairs (you didn't think this would be THAT easy, did you?). Your partner encourages the patient to stand, and says, "Let's go on down to the cot, Mr. Ryan. Then we'll get a couple things done on the way to the hospital."

So, let's stop there. Hopefully before your partner starts him down the stairs...

What are we looking at with Mr. Ryan? He certainly looks the part, but at first glance (with a 3-lead heart monitor), everything looks fine. Right? Let's just do a few more things before we make him walk down those steps...

First, as I'm hoping you would agree, the basics. Oxygen, IV access. Then, let's take a quick glance at the REST of the story. At your direction, your partner grumbles and applies the additional leads. Here is the 12-lead that's acquired:


Does this change your opinion of Mr. Ryan's dilemma? Let's hope so... Is there anything alarming that you feel might need addressed? Do you feel more confident in your diagnostic impression thus far? Maybe that just O2 and IV aren't enough?

Correct. Mr. Ryan is suffering from a significant ST-elevated myocardial infarction, or STEMI. Taking the easy route and not taking the time to acquire a 12-lead would have been a very detrimental route to take in this case. It is certainly appropriate to administer nitroglycerin sublingually, have him chew four baby aspirin, and consider either nitroglycerin intravenously, or in paste form. An opiate, such as Morphine, would also be a wise choice in this case.

Most importantly, it's time to make a transport decision! Are you going to take this patient to your local community hospital, or to a specialty center, for his treatment. The is just one of the many topics that we'll discuss together in future blog entries...

We'll touch back, too, with Mr. Ryan. We'll see how his future unfolds!

Thanks for stopping by my little corner of the "blog-o-sphere." Let's learn something together!

~ rob